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Patient-Centered Outcomes Research and Collaborative Evidence-Based Medical and Dental Practice for Patients with Temporomandibular Joint Disorders

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Temporomandibular Joint and Airway Disorders

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Abstract

This chapter discusses the fundamental principles of the research synthesis process in the context of treatment for TMD. It briefly introduces the ongoing controversy in the etiological factors that lead to TMD, which could be broadly divided into two schools of thought: (1) the muscular cause of TMD (disorders of the joint that occur as a result of excessive or dysregulated activities such as clenching and bruxism of the masticatory muscles) or (2) the articular cause of TMD (the disorders of the joint that are consequential to dysfunctional positioning of the mandible onto the maxillary bone, which itself may result from trauma to the facial skeletal structure, malocclusion particularly with respect to molar contact and support). The chapter discusses perspectives of the arthrokinetic reflex in TMD. The chapter defines the best available evidence and discusses the process leading to EBDM for treating TMD, including the generation and dissemination of evidence-based revisions of clinical practice guidelines (EBrCPGs).

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Notes

  1. 1.

    From Latin, derived from Greek, ginglumos for hinge.

  2. 2.

    From Greek, arthrodia for a synovial joint which allows a gliding motion.

  3. 3.

    The synovium is specialized mesenchymal tissue that facilitates the functionality of the arthrodial joints.

  4. 4.

    Cf., Gray’s anatomy: the anatomical basis of clinical practice. (39th ed.). Edinburgh: Elsevier Churchill Livingstone; Clemente’s Anatomy: A Regional Atlas of the Human Body (6th ed., 2011). Philadelphia: Lippincott.

  5. 5.

    On each side: the masseter, the temporalis (the sphenomandibularis is considered a part of the temporalis by some sources and a distinct muscle by others), the medial pterygoid, and the lateral pterygoid. The muscles of mastication originate in the maxilla and insert into the mandible and allow for TMJ movements during contraction. They are all derived from the first branchial arch during embryonic development and are all innervated by the mandibular (i.e., third) branch of the trigeminal cranial nerve V (V3).

  6. 6.

    The larger of the two muscles of the tympanic cavity responsible for dampening sounds, such as those produced by chewing.

  7. 7.

    Tenses and elevates the soft palate thus protecting the nasopharynx during swallowing.

  8. 8.

    Depresses the mandible and elevates the hyoid during swallowing.

  9. 9.

    Elevates the hyoid during swallowing.

  10. 10.

    The pons, better referred to as pons Varolii (the connection, the bridge of Varolius, because it was first described by Italian anatomist and physician to Pope Gregory XIII, Costanzo Varolio [1543–1575]), is a component of the brainstem that links the medulla oblongata to the thalamus. The pons is considered to be a critical neuroanatomical structure in that it regulates signals, through its specialized nuclei, that control a vast array of functional behaviors, including sleep, respiration, swallowing, bladder control, hearing, equilibrium and movement, taste, eye coordination, facial expressions, facial sensation, and posture. Pontine pathologies lead to difficulty with balance, walking, touch and other senses, swallowing, and speaking (cf., Pritchard and Alloway, 1999, Medical neuroscience; Gray’s anatomy; Clemente’s anatomy, among others).

  11. 11.

    Aka semilunar ganglion, gasserian ganglion, after the Austrian anatomist Johann Lorentz Gasser (1723–1765).

  12. 12.

    Named after Johann Friedrich Meckel the Elder (1724–1774).

  13. 13.

    Masseter, temporalis, medial pterygoid, lateral pterygoid; and tensor veli palatini, mylohyoid, anterior belly of digastric.

  14. 14.

    For example, injury to peripheral branches of V3 nerve may cause partial or total, transient, or chronic paralysis of certain muscles on TMJ, thus leading to a deviation of the jaw on that side and a compensation on the TMJ of the other side (cf., Wallenberg syndrome).

  15. 15.

    The thalamus distributes information between subcortical areas and the cerebral cortex, such as sensory information from V1, V2, and V3. For this purpose, almost every sensory system has a thalamic nucleus that receives sensory signals and sends them to related primary cortical area.

  16. 16.

    The term temporomandibular disorder refers to a group of similarly symptomatic conditions and thus provides a rather vague description of a state, rather than a specific syndrome or condition that affects the temporomandibular joints. Thus, the term temporomandibular joint dysfunction is described as the most common form of temporomandibular disorder. Yet, temporomandibular disorders have been defined as a group of conditions with similar signs and symptoms that affect the temporomandibular joints, the muscles of mastication, or both. It is also the case that TMD is distinct, albeit overlap** somewhat with related syndromes such as the temporomandibular pain and dysfunction syndrome, which is characterized by aching in the muscles of mastication, occasional brief severe pain on chewing, and associated with restricted jaw movement and clicking or pop** sounds (Classification of Chronic Pain, International Association for the Study of Pain; Classification of Chronic Pain, Part II, B. Relatively Localized Syndromes of the Head and Neck; Group III: Craniofacial pain of musculoskeletal origin).

  17. 17.

    A syndrome (Greek, syn, together + dromos, course, progression) describes a constellation of manifestations, clinically recognizable features, which collectively indicate or characterize a condition. These signs can occur together or in a recognized timeline.

  18. 18.

    Bruxism (sleep or wake bruxism) is an oral para-functional activity where there is excessive clenching and grinding of the teeth. The etiology of bruxism is unclear: psychosocial factors may be implicated, and dopaminergic dysfunction and other central nervous system mechanisms may be involved in sleep bruxism.

  19. 19.

    Cf., “Orofacial Pain Fourth Edition. Guidelines for Assessment, Diagnosis, and Management.”

  20. 20.

    An older name for TMD is “Costen’s syndrome,” after James Bray Costen (1895–1962), who, in 1934, described disorder systematically. He suggested that malocclusion, specifically mandibular over-closure, caused TMD and involved ear symptoms, such as tinnitus, otalgia, impaired hearing, and dizziness, including as well burning sensation of the throat, tongue, and side of the nose. He recommended TMD treatment interventions involving correcting occlusion by building up the bite, thus balancing TMJ [35].

  21. 21.

    Secondarily, and because of the proximity of the auriculotemporal nerve to the TMJ, symptoms involving hearing may become evident, including diminished auditory acuity (hearing loss), occasional tinnitus (ringing in the ear), and dizziness.

  22. 22.

    TMD is the second most frequent cause of orofacial pain after dental pain.

  23. 23.

    Luc de Clapiers, Marquis de Vauvenargues (1715–1747), Réflexions et Maximes “…il est. plus aisé de dire des choses nouvelles que de concilier celles qui ont étés dites….”

  24. 24.

    Fallacy consequential to mere ignorance of the facts (argumentum ad ignorantiam), that is, the assumption that a claim is true (here, that all research evidence is equally acceptable for safe use on patients – note: the oath calls health-care providers to do no harm first and foremost [primum non nocere]) simply on the basis of the lack of clearly establishing that in fact that evidence is not safe to be used in patient care; in addition, fallacy consequential to mere adherence to previously held beliefs (argumentum ad antiquitam) (here again, that all research evidence is equally acceptable and safe for patient care) despite cutting edge protocols designed to distinguish acceptable vs. non-acceptable research evidence.

  25. 25.

    “…onus probandi incumbit ei qui dicit, non ei qui negat…” the burden of proof is on the person who makes the claim, not on the person who denies it.

  26. 26.

    AGREE is an instrument developed to provide a basis for defining steps in a shared development approach to produce high-quality clinical practice guidelines revised based upon the best available evidence.

  27. 27.

    That is to say, statistical power even in the case of a meta-analysis performed with few papers.

Abbreviations

EBD:

Evidence-based dentistry

EBDM:

Evidence-based clinical decision-making

EBrCPGs:

Evidence-based revisions of clinical practice guidelines

fMRI:

Functional magnetic resonance imaging

PCOE:

Patient-centered outcomes evaluation

TMD:

Temporomandibular joint disorders

TMJ:

Temporomandibular joint

WHO:

World Health Organization

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Author information

Authors and Affiliations

  1. UCLA School of Dentistry, Los Angeles, CA, USA

    Francesco Chiappelli, André Barkhordarian & G. Gary Demerjian

  2. Evidence-Based Decisions Practice-Based Research Network, Los Angeles, CA, USA

    Francesco Chiappelli, André Barkhordarian & G. Gary Demerjian

  3. Center for TMJ & Sleep Therapy, 175 N. Pennsylvania Ave. #4, Glendora, 91741, CA, USA

    G. Gary Demerjian

Authors
  1. Francesco Chiappelli
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  2. André Barkhordarian
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  3. G. Gary Demerjian
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Correspondence to Francesco Chiappelli .

Editor information

Editors and Affiliations

  1. Center for TMJ & Sleep Therapy, Glendora, CA, USA

    G. Gary Demerjian

  2. Oral Biology and Medicine, UCLA School of Dentistry, Los Angeles, CA, USA

    André Barkhordarian

  3. CHS 63-090, UCLA School of Dentistry, Los Angeles, CA, USA

    Francesco Chiappelli

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Chiappelli, F., Barkhordarian, A., Demerjian, G.G. (2018). Patient-Centered Outcomes Research and Collaborative Evidence-Based Medical and Dental Practice for Patients with Temporomandibular Joint Disorders. In: Demerjian, G., Barkhordarian, A., Chiappelli, F. (eds) Temporomandibular Joint and Airway Disorders. Springer, Cham. https://doi.org/10.1007/978-3-319-76367-5_11

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  • DOI: https://doi.org/10.1007/978-3-319-76367-5_11

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